ASHM Report Back

Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.

Certified as having eliminated HIV & Syphilis transmission from mother to child.

In 2007 the WHO developed the elimination of MTCT policy - all regions have been working towards elimination. There is a structured validation process to approve and celebrate successful countries/regions. Cuba is the first country to reach this target!

Worldwide there's much work to be done - almost 1,000,000 pregnant women have HIV. Assuming a rate of 2% MTCT, there are a still a number of children diagnosed and a significant number more at risk.

HIV and Women's Health was the topic of Wednesday morning's stream. Much interesting and varied work was presented. I will attempt to summarise below.

Damian Jeremia presented his work entitled Prevalence and Factors Associated with Modern Contraceptive use among HIV-positive women aged 15-49 years in Kilimanjaro region, Northern Tanzania.

Women's responses to a questionnaire and interview in Swahili language were aggregated. Results showed that only 54% of these women were using a form of modern contraception. Male condoms were the most common contraceptive method (25.4%). He cited lack of contraception information and lack of combined reproductive health and HIV services being the main barriers in contraception use.

Dr Lisa Noguchi presented on some complex findings from women participating in the S African-based VOICE trial. The VOICE trial is a Phase 2B trial of women using tenofavir as HIV prevention, and one of the eligibilty criteria required having effective contraception. Lisa's secondary analysis of the data looked at injectable Progestin contraception and acquisition of HSV2 Infection. Injectable progestins are the most common contraceptives used in S Africa. Whilst some data suggests hormonal contraception may increase HIV-1 risk for women, recent studies have suggested there are differences in this risk between the 2 commonly available progestin injectables - DMPA and NET-EN. Retrospective analysis of the VOICE data showed HIV-1 was higher for users of DMPA vs. NET-EN (aHR 1.41, 95% CI 1.06-1.89) p=0.02. However, the risk of HSV-2 acquisition between the 2 types of injectables turned out to be not significantly different. She noted that the data was extracted from the VOICE study retrospectively, which was originally designed to demonstrate different data and results could therefore be prone to bias.

Shaun Barnabas presented longditudinal cohort data on genital symptoms and STIs in just under 300 women aged 16-22 years in different cities of S Africa. The Cape Town cohort was more risky in behaviour with a high prevalence in STIs vs. Johannesburg, specifically a higher prevalence of chlamdyia, gonorrhoea and HSV-2. There were low rates of symptoms reported across the board,with "normal vaginal discharge" being the most common symptom (58%) and "abnormal discharge" 8% at baseline.There was little correlation between symptoms and STIs. This is an issue as S African guidelines are based on syndromic management, thus potential for under treatment is significant.

His final question was "Is it time for the SA government to move away from syndromic management?" The resounding answer from the audience response was "Yes!".

Alison Norris educated us about the gender differences in HIV testing and knowledge in Rural Malawi, one of the poorest per capita countries in the world. There were encouragingly very high rates of HIV testing in both sexes. Most powerful predictor in whether someone of either sex had ever had an HIV test was knowing the partner had received a test. Ultimately their prediction that there would be significant differences between testing and knowledge between men and women was unfounded.

A/Prof Sheona Mitchell talked on uptake of cervical cancer screening among HIV positive women participating in a pilot RCT in Uganda: the ASPIRE project (a collaborative study between Canada and Uganda). The aim of the ASPIRE project is to inform policy makers about cervical screening programs in resource poor areas.

They studied 500 women in an urban community in Kampala. Usual cervical screening involves visual pelvic speculum exam with acetic acid application.ie invasive. The potential for a less invasive test such as a self-collected swab detecting high-risk HPV strains is a novel, attractive approach for low-resource settings. HIV positive and negative women were randomised to speculum visual exam or self-collected swab.

Self collection of swabs had a high uptake in both HIV pos and neg women. It was found to highly acceptable, improved access and had high rates of retention going forward to further exam and treatment (compared to visual exam alone). She was hopeful of future POCT for the HPV swab to further reduce barriers to cervical screening uptake.

Elizabeth Fearon then finished up the session by presenting interesting data on a method to estimate the national prevalence of HIV among female sex workers in Zimbabwe by pooling data from Multiple Sampling Surveys and Programme Consultations.

My take home message from all of the above presentations is that there is much great innovative research going on in some of the most resource-stretched places on Earth. Many small steps are being made towards improving access to screening, testing, support and treatment for women (both HIV positive and negative) from these difficult to reach populations and places. But there is still a long way to go.

My apologies for not getting this blog out earlier (time travel and jet lag)

What a great conference. It has been great pleasure to meet many of the 2015 CROI ASHM bloggers.

There has been a lot of research and data looking at HIV infection and chronic systemic inflammation measured by an array of inflammatory biomarkers to predict HIV morbidity from cardiovascular disease, Neuro cognitive disease and cancers to name a few. This research has highlighted the importance of HIV infection and the risk of HIV morbidities especially in older age groups and that predictive value of traditional markers in HIV infection such as CD4 and VL must be further evaluated.

To continue on this theme of HIV morbidity; Steven Grindspoon of Massachusetts General Hospital.

This plenary session presented that the understanding of current CVD risk in HIV is limited as are treatment preventions. Chronic inflammatory biomarkers can be used as predictive markers. HIV individuals at risk of CVD risk are not identified through traditional screening pathways. We should not forget the HIV drug combination and other factors such as smoking, body fat composition, type 2 diabetes, platelet dysfunction, endothelial, renal function that contribute to CVD.

HIV immune activation relates to novel atherosclerotic phenotype in HIV. It is therefore vital to identify these individuals who may be at risk of CVD. With the current CVD risk stratification many individuals would not receive recommendation for statin treatment under current guidelines.

It is known that statins decrease CVD events in non HIV patients with low LDL and raised CRP (LDL lowering and dampening immune activation)

Newer statins do not effect glucose and less likely to have drug interactions with ARVs. Pitavastatin is primarily metabolised by glucoronidation. Minimally metabolised by CYP3A which have very little drug interaction with ARVs and no dose reduction needed

REPRIEVE a RCT, looking at Pitavastatin versus placebo in asymptomatic HIV participants with a cardiac risk score of less than 7.5

Cynthia Firnhaber presented a one year follow up cervical screening in HIV positive women in South Africa, this is significantly poignant as Cervical cancer is the highest cancer in women in Africa and responsible for 23% of all cancers. The risk of cervical cancer in HIV positive women is 3-6% higher than the general population.

In this cohort of 671 women 392, 92% were on ARVs, 80% were fully suppressed, average CD4.

Cynthia Furnhaber, University of Witswatersrand, Johannesburg, South Africa

One year follow up of HIV positive women, screen with VIA (visual inspection with acetic acid), HPV and cytology

Cervical cancer is the leading cause of death in South Africa, with the risk of developing cervical cancer in HIV cancer 3-6 times the general population. In the WHO Africa region AFRO in 2012, 250,317 died of cancer (23% cervical cancer).

837 women enrolled at baseline and 677 reviewed at one year. Characteristics such as age, CD4, VL, HPV were analysed separately.

Baseline 33% HSIL, 40%LSIL, 27% Normal a

One year follow up HSIL 7%, LSIL 70%, and Normal 23%

Average CD4 387, 87% VL< 1000, 93% ARVs

16% New HPV infection, 48% cleared HPV infection,

22% Progressed, 63% regressed via VIA

This study concluded that even HIV positive women who are on treatment have a significant risk of CIN progression and that cervical screening and access to healthcare is imperative to ensure gains in health for HIV positive women.

A eye opening plenary by Frances M Cowan, University College London, London, United Kingdom

The Price of Selling Sex: HIV Among Female Sex Workers—The Context and the Public Health Response

Globally female sex workers (FSW) are more 15% more likely to have HIV than general population. Meta-Analysis of the Burden of HIV in FSW –Asia 29% (countries not defined), Latin America 12%, Sub Saharan Africa 12% and modes of HIV transmission probably underestimate the effect of FSW in HIV transmission globally.

This talk then looked at prevention framework, legislation against violence against sex worker could reduce HIV transmission by 17-20% 0ver next decade, decrimalising sex work reduce HIV transmissions by 33-46% over the next decade.

Prevention framework should be through (individual, peers, community, public policy, and environment)

Systemic review and met analysis of 22 studies and 33,000 FSW, showed a significant reduction in HIV, STIs (Gonorrhea, Chlamydia, Syphilis) and an increase in consistent condom usage with new and regular clients. Also discussed were newer biomedical interventions such as PrEP, PEP and HIV treatment to prevent MTCT.

Conclusions

Proper inclusion of sex workers and other key populations is essential to reach 90:90:90

The Thursday Afternoon Themed discussion PEP- Remember me?

Kenneth H. Mayer

Fenway Health, Boston, MA, United States

Overview – Changes with PEP is transmission risk is one off event which needs prompt response with treatment, mostly conducted with animal studies and occupational studies, HIV transmission is relatively inefficient <1%. Guidelines are based on peer review studies. PEP guidelines vary with country to country even centre to centre.

The Opening Ceremony: First, a rant…there is a history to AIDS and Sunday night in Washington that history was reconstructed. It was reconstructed as one of common cause and compassion, driven by our collective faiths and heritage and the deluded notion that we have all been in this together, fighting the good fight, supporting each other in some sort of quasi evangelical quest for social justice, wherein we are blind to difference and saved by science and gods.

Every International AIDS Conference has its own local flavour, and that is appropriate; I know I am in America, a land far less cynical and irreligious than my own. But I am here, I was told, because of the fight. And I am here, I was told, because of my faith. Fighting together, fighting AIDS, fighting discrimination, fighting the naysayers who don't think treatment is prevention, who don't think we are all the same in some god's eyes. Fight on brothers and sisters! I am accompanied, I was told, by my brothers and sisters of faith, walking into the light of an AIDS free generation. An Elder of the local indigenous people waved a feather at me and a preacher called me a crusader; call me ungrateful but I resent having my motivations, my reasons for why I work in this field, presumed and attributed to someone else's idea of what makes this meaningful.

Again, I was told that I am "standing at a unique point in history", "at a defining moment". Oh, really? ... Still? ... These people have been telling me that I am standing at a unique point, 'facing a (perpetually) closing window of opportunity' for over twenty years now. When exactly is that window of opportunity going to shut? The mood of this conference would not be one of diminishing opportunity; quite the opposite, there would be more optimism of 'cure' and truly achieving an AIDS free generation than ever before. But this does not, it seems, suit the drama and theatrics of an opening night ceremony, devoted to the drama of AIDS.

The Mayor of this fair town assured me that 'AIDS knows no boundaries and crosses borders at will'. Well, yes sir, it does but the fact is it stays where it likes, stays where it meets least resistance and while it might occasionally cross into the leafy streets of Georgetown or Dupont Circle, it actually has taken up residence in your beltway and Black neighbourhoods with a vengeance that should shame you. Fact is, you have a better chance of accessing testing, getting into care and onto treatment and staying in care and on treatment in the Highlands of Papua New Guinea than you do if you are Black and gay, Black and injecting, Black and selling sex, Black and transgender, Black and any or all of the above, and you live in this city. Several presentations at this conference would show us data demonstrating this. But I digress, turns out the Mayor is "personally committed to finding a cure".